Does Trump Even Understand the Health-Care Bill He Helped Pass?

The Republican push to repeal Obamacare was always more about about politics than policy. For seven years, G.O.P. lawmakers held symbolic votes to kill Barack Obama’s signature legislation, and successfully ran against the bill in two midterm elections, but never offered up alternative legislation of their own. They struggled to come up with a plan when Donald Trump unexpectedly assumed the presidency, and rushed to hold a vote on a slapdash repeal bill to coincide with the seventh anniversary of Obamacare’s signing—the ultimate “screw you” to Trump’s predecessor. Lost in the political theater was any effort to actually improve health care coverage, which the G.O.P. bill would have stripped from some 24 million people.

House Speaker Paul Ryan famously pulled the American Health Care Act after conceding that he didn’t have the votes in the House. But efforts to revive the zombie Trumpcare bill limped on, surviving multiple rounds of negotiations with conservatives who insisted the legislation cover fewer people and provide fewer benefits. Now, after a series of starts and stops, the House finally voted Thursday to repeal and replace Obamacare, passing the A.H.C.A. by 217-213. In the end, 20 Republicans voted “no.”

It is not clear whether the 217 lawmakers who supported the bill truly understand what they voted for, or what electoral consequences they may soon face. The crux of the debate over the A.H.C.A. in recent weeks involved the so-called MacArthur amendment, which would give states flexibility to opt out of Obamacare’s “essential health benefits” (things like hospitalization and maternity care) and allow health insurance providers to charge individuals with lapsed coverage higher premiums based on their “health status.” Critics of the amendment argue it would effectively price people with pre-existing conditions out of the market. Republicans counter that states would only be allowed to strip those Obamacare protections away if they created a separate high-risk insurance pool to help cover those costs, though experts say the $138 billion allotted by the legislation would fall far short of the amount required to adequately provide assistance to sick people whose costs would skyrocket under the G.O.P. plan.

Donald Trump, who toldFace the Nation on Sunday that “pre-existing conditions are in the bill” and “we cover it beautifully,” either does not understand the policy he promoted or else he is being dishonest about its effects. On Monday, when pressed in a Bloomberg interview on whether he would sign a bill that allowed insurance providers to raise premiums for people with existing health problems, Trump pushed back. “Well, we are protecting pre-existing conditions,” he asserted. “It’ll be every good—every bit as good on pre-existing conditions as Obamacare.”

This is plainly false, as several members of Trump’s own party inadvertently explained earlier this week. “That's not my understanding of the way the bill has been reframed,” Rep. Mo Brookssaid cautiously after he was asked by CNN’s Jake Tapper whether the president wanted the legislation changed or was merely confused. “My understanding is that it will allow insurance companies to require people who have higher health-care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy.” Rep. Warren Davidson was even blunter when he was asked about the bill’s deep cuts to Medicaid, which Trump had also promised not to touch. “I don’t know anything about your son,” he told a woman at a town hall who asked why her adult child was not deserving of care. “But as you described him, his skills are focused in an industry that doesn’t have the kind of options that you want him to have for health care. So, I don’t believe that these taxpayers here are entitled to give that to him.”

It could be that president’s advisers and Capitol Hill allies simply misled him. On the campaign trail, Trump repeatedly vowed to provide insurance for everybody, and many of his supporters voted for him assuming that Republican threats to cut benefits would not affect them. Earlier this week, Trump reportedly picked up the phone to seek reassurance that A.H.C.A. would uphold his promises. “Is what we are going to do going to take care of people?” he asked. The answer he continues to get, however, is that it will. Reince Priebus, who was blamed for the failure of Trumpcare 1.0 and was desperate to see the revised bill pass, worked “nonstop” to secure the votes. Paul Ryan, who does not believe in the concept of insurance, tweeted that it was “VERIFIED” that the MacArthur amendment “protects people with pre-existing conditions,” a claim that Politifact rated “Mostly False.”

If Trump is confused about how the G.O.P. bill works, he’s not alone. Rep. Fred Upton, who temporarily threw the vote-count into chaos when he announced that the bill’s $130 billion allotment for high-risk pools was insufficient, was later easily won over after Trump approved an amendment to toss in an additional $8 billion—an amount health-care experts dismissed as inconsequential. “Is it enough money? I don’t know,” Upton admitted Wednesday afternoon. “I asked if this is going to get it covered and the answer was yes—that’s what I needed.” Senate Minority Leader Chuck Schumer likened Upton’s amendment to “administering cough syrup to someone with stage four cancer.”

Much of the uncertainty surrounding the bill’s likely impact on Americans was rooted in the Republican leadership’s refusal to wait to obtain a score from the nonpartisan Congressional Budget Office. In March, the C.B.O. estimated that the initial version of the A.H.C.A. would ultimately result in 24 million fewer people being insured than under current law. Since then, revisions have only made the legislation less generous, granting states additional flexibility to gut Medicaid and strip protections for people with pre-existing conditions. Yet Republicans voted Thursday without an updated assessment of the bill’s impact. (The Senate is expected to receive a new C.B.O. score before they evaluate the bill—a process that is likely to result in major changes.)

Other potentially far-reaching provisions of the G.O.P. bill were hardly considered or debated in public. As The Wall Street Journalnotes, under the waiver system that would allow states to opt-out of certain Obamacare regulations, large employers could cherry-pick benefit plans from states with lower standards to cut back on their coverage costs. Women will also be disproportionately impacted by the MacArthur amendment, which would allow sexual assault and pregnancy to be classified as pre-existing conditions. Medicaid cuts could impact benefits and services for millions of students with mental and physical disabilities. (Republican lawmakers did vote to scrap the provision in the bill that would have allowed them to retain the Obamacare regulations protecting individuals with pre-existing conditions on Thursday.)

The question remains, of course, whether the bill can make it out of the Senate. The conventional wisdom was that moderate Republicans in the upper chamber would never allow such a bill to pass, but the political winds have appeared to shift, and some lawmakers have been appeased by the extra flexibility the most recent revision gives to states. Recent reports suggest the legislation is hardly dead on arrival, though leadership will have to win over a few recalcitrant G.O.P. senators, including Susan Collins,Ted Cruz,Rand Paul, and Mike Lee to pass. (Republicans can only lose two senators from their camp for the bill to fail.)

Should the G.O.P. health-care bill become law, there is a thin silver lining for Democrats: public opinion is on their side, and it is impossible to continue obfuscating the bill’s effects once they begin to be widely felt. With support for Obamacare at an all-time high and only a small sliver of voters backing A.H.C.A., a successful repeal vote would almost certainly set Republicans up for an electoral Waterloo in 2018 and 2020. The human tragedy that would take place in those intervening years is hard to fathom.